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Health Effects Among World Trade Center Responders: The World Trade Center Worker and Volunteer Medical Screening Program. Robin Herbert M.D. World Trade Center Worker and Volunteer Medical Screening Program Mount Sinai School of Medicine. Initial Human Health Concerns.

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slide1

Health Effects Among World Trade Center Responders: The World Trade Center Worker and Volunteer Medical Screening Program

Robin Herbert M.D.

World Trade Center Worker and Volunteer Medical Screening Program

Mount Sinai School of Medicine

initial human health concerns
Initial Human Health Concerns
  • Upper airway inflammation
    • Rhinitis/sinusitis
    • Pharyngitis
    • Laryngitis/tracheitis
    • Reactive upper airway dysfunction
  • Bronchitis
  • Reactive airway disease (RADS)/ Asthma
initial human health concerns9
Initial Human Health Concerns
  • Musculoskeletal injuries
    • Unstable, hazardous physical environment
      • Debris overlying voids
      • Dust suppression wets dusted surfaces
    • Concern about acute injury, with longer-term musculoskeletal sequelae
    • Actual acute trauma rate remarkably low
initial human health concerns10
Initial Human Health Concerns
  • Psychological effects
    • PTSD
    • Anxiety
    • Depression
  • Social and economic consequences
    • Loss of employment due to physical and/or mental health conditions, economy
    • Impact on family functioning
    • Increase in substance/ETOH use
wtc worker and volunteer medical screening program
WTC Worker and Volunteer Medical Screening Program
  • Funded by NIOSH to rapidly establish a clinical program to provide 12,000 free standardized screening exams to WTC responders (NYC, NY/NJ, nationally)
  • Examination purposes:
    • To identify current WTC-related physical and mental health problems
    • To serve as baseline for future exams
    • To provide meaningful aggregate data in absence of control groups
medical screening components
Medical Screening Components
  • Self and interviewer-administered medical questionnaires
  • Physician-administered examination
  • Interviewer-administered exposure assessment questionnaire
  • Spirometry with bronchodilator
  • Chest x-ray
  • Routine blood work
  • Psychological screening and evaluation
clinical centers
Clinical Centers
  • Mount Sinai Center for Occupational and Environmental Clinic
  • Bellevue/NYU Occupational and Environmental Clinic
  • SUNY Stony Brook/Long Island Occupational and Environmental Health Center (Nassau and Suffolk counties)
  • Queens College Center for the Biology and of Natural Systems
  • UMDNJ Environmental and Occupational Health Services Institute (Piscataway, NJ)
  • 35 Association of Occupational and Environmental Clinics across the country, 2 independent clinical sites in Ca. and 1 independent clinical site in Florida
between july 16 2002 and july 14 2004 11 768 wtc responders were examined
Between July 16, 2002 and July 14,2004, 11,768 WTC Responders were examined
  • Construction (2800+)
  • Law enforcement (1800+)
  • Technical and Utilities (600+)
  • Public sector- blue collar (500+)
  • Transportation (300+)
  • Cleaning/Maintenance (200+)
  • Ironworkers (200+)
mmwr report

MMWR Report:

Reported on health of 1138 WTC responders seen at Mount Sinai between 7/16/02 and 12/31/02

eligibility criteria 12 31 02
Eligibility criteria (12/31/02)
  • Minimum of 24 hours working/volunteering during September 11-30, 2001
  • Or
  • >80 hours during September 11-November 30,2001
  • Either south of Canal Street, the Staten Island landfill, or barge loading piers
  • Employees of the Office of the Chief Medical Examiner
  • FDNY and State of New York employees had access to other screening programs and were not eligible
initial arrival at wtc site
Initial Arrival at WTC site
  • Exposure:
    • 525 (46%) worked on WTC rescue and recovery efforts on 9/11/01.
    • 963 (84%) worked or volunteered during 9/11/01 – 9/14/01
  • 239 (21%) reported using appropriate respiratory protection through 9/14/01
  • Median length of time worked on the WTC efforts was 966 hours (range: 24 – 4080 hours).
pulmonary symptoms n 1138
Pulmonary Symptoms (n=1138)
  • 682 (60%) reported at least one WTC-related pulmonary symptom (dry cough, chest tightness, shortness of breath, wheezing, awakened by shortness of breath).
  • 479 (42%) were still experiencing at least one WTC-related pulmonary symptom in the month before the screening examination.
self reported lower respiratory symptoms previous history and worsened
Self-reported Lower Respiratory Symptoms:Previous History and Worsened

1 A small proportion of participants (n=2-19) are missing data on this question, except for “chest tightness,” n=164 missing

self reported lower respiratory symptoms incidence new onset and persistent
Self-reported Lower Respiratory Symptoms:Incidence (new onset) and Persistent

1 Based on a denominator of 1138

upper airway symptoms n 1138
Upper Airway Symptoms (n=1138)
  • 836 (74%) reported at least one WTC-related ENT symptom while at the WTC site (throat irritation, blowing nose more than usual, head or sinus congestion, postnasal discharge, and/or nasal irritation).
  • 643 (57%) were still experiencing at least one ENT symptom in the month before the screening examination.
self reported upper respiratory symptoms previous history and worsened
Self-reported Upper Respiratory Symptoms:Previous History and Worsened

1 A small proportion of participants (=2-19) are missing data on this question, except for “chest tightness,” n=164 missing

2 All are “excluding colds,” except “facial pain or pressure”

self reported upper respiratory symptoms previous history and worsened cont
Self-reported Upper Respiratory Symptoms:Previous History and Worsened (cont.)

1 A small proportion of participants (=2-19) are missing data on this question, except for “chest tightness,” n=164 missing

2 All are “excluding colds,” except “facial pain or pressure”

self reported upper respiratory symptoms incident new onset and persistent
Self-reported Upper Respiratory Symptoms:Incident (new onset) and Persistent

1 All are “excluding colds,” except “facial pain or pressure”

2 Based on a denominator of 1138

self reported upper respiratory symptoms incident new onset and persistent cont
Self-reported Upper Respiratory Symptoms:Incident (new onset) and Persistent (cont.)

1 All are “excluding colds,” except “facial pain or pressure”

2 Based on a denominator of 1138

slide31

Self-reported Other Symptoms:

5 most prevalent symptoms

slide32

Self-reported Other Symptoms:

5 most prevalent symptoms

self reported other symptoms previous history and worsened
Self-reported Other Symptoms: Previous history and Worsened

1 A small proportion of participants (n=4-20) is missing data on specific questions

pulmonary function tests
Pulmonary Function Tests
  • Pulmonary function tests demonstrated a high prevalence of respiratory abnormalities.
  • 360 (32%) had restriction, obstruction, or mixed abnormalities.
  • High prevalence of PFT abnormalities not likely to be due to smoking – 55% of sample never smoked.
spirometry results
Spirometry Results

Footnotes:

Includes the 1,085 participants with 3 good spirometry maneuvers and valid smoking status responses

LLN = lower limit of the normal range, per Hankinson et al. 1999

Obstruction = FEV1/FVC < LLN and FVC > LLN (pre-bronchodilator)

Restriction = FVC < LLN and FEV1/FVC > LLN

Obstruction and low FVC = FEV1/FVC < LLN and FVC < LLN

* BD (bronchodilator) response was defined as an increase of > 12% and > 0.2L in either FVC or FEV1

after inhaling albuterol

** Includes 75 participants with a normal FVC after bronchodilator (pseudo-restriction)

slide38

Comparison of Spirometry Results to

“Never Smokers” in the General Population*

using NHANES III data

*Sample of employed, adult, white males

mental health screening questionnaire results by category
Mental Health Screening Questionnaire Results by Category

* If exceeds threshold on General Health Questionnaire (GHQ), PCL, Patient Health

Questionnaire (PHQ), or Life Impact Survey

† If suicidal ideation was indicated on GHQ or PHQ.

main conclusions
Main Conclusions
  • Primarily technical/utilities (25%), law enforcement (21%), construction (18%)
  • 46% worked on WTC-related efforts on 9/11/01 and 84% 9/11-9/14; BUT only 21% used respiratory protection during that time
  • 60% had WTC-related LA (new/worsened) while at WTC
  • 74% had WTC-related UA (new/worsened) while at WTC
  • 40% had incident WTC-related persistent LA to one month prior to screening
  • 50% had incident WTC-related persistent UA to one month prior to screening
slide42

Main Conclusions (cont.)

  • Fully 851 (75%) had at least one persistent WTC symptom
  • Among those 851 (75%) with any persistent symptom, an average of 32 weeks elapsed since they stopped working at WTC site or since close of site
  • PFTs- 33% abnormal
    • Among 599 non-smokers, 31% abnormal vs. 13% compared with NHANES III
limitations
Limitations
  • No reliable statistics exist on the size or composition of the exposed worker/volunteer population
    • Determining participation rates for screening program not possible
  • Screened population might over represent those most affected
    • Those examined earlier might not be representative of all persons screened
    • Persons examined earlier might have had more severe health problems and sought out program for that reason
  • Ability to measure accurately the impact of WTC exposures on responders’ is limited because of absence of pre-9/11 symptom prevalence and pulmonary function tests for these participants
discussion wtc health effects
Discussion:WTC Health Effects
  • WTC related symptoms have predominantly involved the upper and lower respiratory tracts and/or responders’ mental health
  • WTC related physical and mental health symptoms have been surprisingly persistent
  • Pattern of upper and lower respiratory and mental health symptoms is similar to that seen seen among NYFD and office workers from WTC vicinity
discussion wtc health effects45
Discussion:WTC Health Effects
  • Many with persistent symptoms have received either no clinical care or inappropriate medical evaluation and/or treatment
  • Linkage of mental health component to physical health evaluation has been very successful
discussion unmet public health needs
Discussion: unmet public health needs
  • Access to follow up medical and mental health care has been difficult:
    • For WTC-related problems: workers compensation delays, few occupational medicine specialists
    • For WTC-related mental health problems: few psychiatrists or other mental health providers are familiar with WC, need for Polish/Spanish speaking MH experts
    • For other medical problems: medically indigent
discussion challenges in primary prevention of wtc health effects
Discussion:challenges in primary prevention of WTC health effects
  • Many of the responders either did not have or did not use adequate respiratory protection in the immediate aftermath of the disaster
  • Many of the types of workers who responded did not work in occupations or industries where they were prepared to respond to acts of terrorism
  • Some occupational groups involved in the response were vulnerable workers such as non-English-speaking immigrants (e.g., day laborers/cleaners) who may have had less access to respiratory protection and health and safety training
discussion what is the significance of this for residents and workers in the wtc area
Discussion: What is the significance of this for residents and workers in the WTC area?
  • Residents and workers from area surrounding WTC-site certainly also sustained exposure to both air contaminants and psychological traumatogens
  • Health burden not yet adequately evaluated
acknowledgements
Acknowledgements
  • The entire staff of the World Trade Center Worker and Volunteer Medical Screening Program
  • Bellevue/NYU Occupational & Environmental Medicine Clinic
  • Center for the Biology of Natural Systems at Queens College
  • SUNY Stony Brook/Long Island Occupational and Environmental Health Clinic
  • Environmental & Occupational Health Sciences Institute at UMDNJ-Robert Wood Johnson Medical School/New Jersey
  • The Association of Occupational and Environmental Clinics
  • NIOSH/CDC
  • OUR WTC-RESPONDER PATIENTS!!!!!